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Enrollment

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Our Group Benefits Enrollment forms are your passport to comprehensive insurance coverage. Let’s make this process smooth and hassle-free.

Timing Matters: Complete and sign your enrollment form within 31 days of becoming eligible for insurance coverage.

Select the appropriate Group Benefits Enrollment Form from the list below.

  • Dependent Child Eligibility The file was published on 5/2024

    The employee is applying for over age disabled dependent for continuation of insurance beyond dependent termination age specified in the policy.

  • Dependent Student Eligibility The file was published on 5/2024

    The employee is applying for the continuation of insurance for a child over the age of 21, who is attending an educational institution.

  • Essentials Basic and Enhanced Employee Application The file was published on 5/2024

    For Essential Basic and Enhanced groups with an effective date before October 1, 2024. Enroll employees into the Essentials Basic and Enhanced plan. Should be completed and signed by the employee no later than 31 days after the date the employee first becomes eligible for insurance coverage.

  • Group Benefits Enrollment – Employee Application The file was published on 5/2024

    For Choice groups and Essential groups with an effective date on or after October 1, 2024. Enroll employees into the group insurance plan. Should be completed and signed by the employee no later than 31 days after the date the employee first becomes eligible for insurance coverage.